Journal of Physiotherapy 68 (2022) 153–155
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s
Editorial
Clinical education of physiotherapy students
Alan Reubenson a, Mark R Elkins b,c
a
Curtin School of Allied Health, Curtin University, Perth, Australia; b Editor, Journal of Physiotherapy; c Faculty of Medicine and Health, University of Sydney, Sydney, Australia
This Editorial introduces Journal of Physiotherapy’s article
collection on clinical education of physiotherapy students. The article
collection has been curated from papers published in the journal to
facilitate access to important findings in this field, highlight trends in
the research and summarise avenues for further investigation. The
collected articles show educational models, novel approaches to
finding clinical placements, early educational initiatives taken in
response to the coronavirus disease 2019 (COVID-19) pandemic, the
current status of entry-level physiotherapy assessment, and insights
into future directions for physiotherapy education.
Models of clinical education
In 2021, the total number of entry-level physiotherapy programs
in the member nations of World Physiotherapy had risen to about
3,800.1,2 For example, in Australia and New Zealand the number of
universities offering such courses has risen to 27 and programs of-
fering entry-level physiotherapy programs have increased sharply
over the past two decades (Figure 1).3 Consequently, physiotherapy
student enrolments have also increased, with over 10,000 students
enrolled in entry-level courses in Australia at 30 June 2020.4 This has
increased competition for clinical placements. Many undergraduate
physiotherapy programs also face financial pressures; for example,
recent changes to higher education funding in Australia have caused a
net decrease in funding support of around 9%.5 These changes
highlight the need for more-efficient models of education and the
importance of willingness to embrace organisational change.6
Peer-assisted learning
Peer-assisted learning (PAL) in clinical placements involves stu-
dents working in pairs or larger groups, who undertake structured
and/or informal learning activities together (eg, provide social sup-
port and peer feedback on performance). Potential benefits of PAL
models include those for students (eg, reduce anxiety by creating a
safe learning environment and develop collaborative skills), clinical
educators (eg, reduce workload as students support each other and
can undertake structured learning tasks without direct involvement)
and education providers (eg, build clinical placement capacity). A
crossover trial by Sevenhuysen et al gave third-year physiotherapy
students an opportunity to experience a structured PAL clinical
placement and a traditional clinical placement.7 The PAL model was
new to students and educators so training in the use of the PAL model
was provided prior to the 5-week clinical placement. Student per-
formance was similar with the two models. Although the PAL model
reduced educator workload and increased student feedback, both
educators and students were more satisfied with the traditional
model.7 Sevenhuysen et al then used focus groups to explore student
https://doi.org/10.1016/j.jphys.2022.05.012
1836-9553/© 2022 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
and educator perspectives of the PAL model.8 The respondents re-
ported that PAL can help to position students as active learners
through reduced dependence on the clinical educator, heightened
roles in observing practice, and making and communicating evalua-
tive judgments about quality of practice. The authors also concluded
that a more flexible use of PAL activities might provide students and
educators with more agency, and empowering educators to design
worthwhile PAL activities might lead to increased adoption and
acceptance of the PAL clinical placement model.
Simulation
Chipchase et al described how some in the profession have suc-
cessfully embedded the use of simulation into entry-level and post-
graduate training and assessment.3 They questioned whether simu-
lation practices could extend further; for example, by using students
as simulated patients, by using simulation to a greater extent in post-
graduate training and even by using simulation to provide training for
other workplace settings (eg, private practice). They concluded with
some questions and challenges to all stakeholders (clinicians, edu-
cators, researchers and professional bodies) in meeting the future
needs of the profession, calling for informal and formal leadership to
drive cultural transformation as well as the need to work together in
strong, collaborative partnerships in order to educate the next
generation of safe and effective practitioners.
Private practice placements
Traditionally, most physiotherapy clinical placements in Australia
take place in public hospitals, yet most graduates work in the private
sector. A mixed-methods study quantified and characterised the use
of private practice for clinical placements in Australia.9 Clinical edu-
cation managers (CEMs) were also interviewed to discern their
perceived benefits, risks, barriers and enablers of private practice
clinical placements.9 With a 95% response rate from eligible Austra-
lian universities, the study provides very robust data. Based on 2017
data, 44% of students undertook at least one 5-week placement in
private practice and this accounted for 9% of all 5-week placements –
an encouraging increase compared with previous reports. Key find-
ings from the CEMs’ perspective were that private practice place-
ments were safe and beneficial for students, practices and
universities. The main identified risks were related to quality and
consistency of student experience with no real risk to clients or ser-
vice. The main barriers that were highlighted were time costs (to both
private practitioners and CEMs), lack of space in some private prac-
tices and potential loss of earning as the CEMs recognised that su-
pervising students does take time. The CEMs felt that there was no
single superior educational model and that with more time and
154
50
Extended graduate entry Masters degrees
40
Graduate entry Masters degrees
Bachelor and Bachelor with Honours degrees
Physiotherapy courses (n)
30
20
10
0
1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2022
Year
Figure 1. Growth in the number of accredited physiotherapy programs in Australia and New Zealand.a,b Modified from Chipchase et al.3
a
When a university offers both a Bachelor degree and a Bachelor degree with Honours degree, these have been counted as one program because the Honours program is generally
nested within the Bachelor degree.
b
Some universities operate programs across different locations and in these cases are counted as multiple programs because they require staffing and resources at multiple sites.
resources there were opportunities for working with private practi-
tioners in partnership to enhance learning experiences and build
capacity for clinical placements in the private sector. To facilitate this,
the paper lists a range of available training and support resources.9
Expansion of clinical placements in private practice raises the
question: do students who undertake more private practice place-
ments achieve equivalent performance outcomes as their peers who
undertake fewer private practice placements? Lawton et al undertook
a large-scale, longitudinal, retrospective study comparing final
Assessment of Physiotherapy Practice (APP) results between public and
private sector placements of 284 students at one university.10 Student
performance did not substantially differ between the two sectors.
Subsequently, the 284 APP results from the final placement in the
course were compared with final placement results from 517 students
completing a similar course at other universities, which again found no
important differences. This support for expanding private practice
placements into the private sector should help meet the growing
demand for clinical placements and permit better matching of
placement exposure to workforce employment destinations.
Non-metropolitan placements
Another way to respond to increasing demands for clinical
placements would be to increase placements in non-metropolitan
centres. Francis-Cracknell et al11 interviewed first-year students
about their perceptions of upcoming non-metropolitan placements,
third-year and fourth-year students about their perceptions of
completed non-metropolitan placements, and clinical educators from
non-metropolitan sites. Roughly half of the first-year students (53%)
had an unfavourable perception of non-metropolitan placements,
especially those from a metropolitan upbringing. The third-year and
fourth-year students and the clinical educators suggested strategies
to support and prepare students for non-metropolitan placements:
tailoring preparation for students, paired rather than individual
placements and near-peer presentations for physiotherapy students
prior to undertaking non-metropolitan placements. Other possible
facilitators were dedicated clinical coordinator positions, travel sub-
sidies and affordable accommodation. Students who have positive
experiences in non-metropolitan clinical placements are more likely
to seek employment in these settings.12 Another advantage of
increasing non-metropolitan placements and their acceptability may
Editorial
help to address the unmet healthcare needs of communities in
non-metropolitan areas.13
Clinical education in the COVID-19 pandemic
The reduction in face-to-face interactions and changes in health-
care delivery during the pandemic have created many challenges14
but also provided opportunities for innovation in clinical education.
Clinical research placements
One such example is the advent of the clinical research placement,
where clinical education is delivered in the context of research, with
students involved in research projects that include delivery of
evidence-based care.15 Dario and Simic15 described the planning,
development and implementation of pilot projects where clinical
placements were embedded in research trials: one in knee osteoar-
thritis and one in low back pain. The model was co-designed by ac-
ademics and researchers. Telehealth trials were identified as the best
option in the pandemic and shared care models were used, with
experienced physiotherapists leading the interventions and students
supporting and performing some clinical and research-related tasks.
The placements were assessed using the APP across the 5-week
placement. Following successful trials, these placements are now
embedded in the physiotherapy program at the University of Sydney
and in partnership with a local health service (clinical activities) and
research institute (research activities). Quality assurance processes
suggest positive outcomes as well as some barriers. Although this
placement addressed an immediate need, it also provides a future
opportunity to expand clinical placement capacity and develop
research and evidence-based practice skills.
Simulation-based assessment of clinical competence
Pandemic restrictions also challenged assessment of practical
skills when determining clinical competence in entry-level physio-
therapy education16 and with overseas-qualified physiotherapists.17
Tognon et al17 described the steps taken (eg, environmental scan
and analysis of existing mechanisms of remote assessment of clinical
competence) and considerations explored (eg, whether assessing
one’s evaluative judgement of a physical task would be sufficient
 Editorial
without testing the actual performance) by the Australian Physio-
therapy Council in determining how assessment of clinical compe-
tence could be improved and future-proofed to deal with such
disruptions. The authors did not identify any model of remote
assessment that might replace the current simulation-based clinical
assessment but did provide interesting considerations for the future.
Assessment of Physiotherapy Practice tool
The APP tool was originally developed more than a decade ago.18 It
contains 20 items covering seven domains of physiotherapy practice:
professional behaviour, communication, assessment, analysis/plan-
ning, intervention, evidence-based practice, and risk management.
Each item is scored on a 5-point scale (0 = infrequently/rarely dem-
onstrates performance indicators to 4 = demonstrates most perfor-
mance indicators to an excellent standard). The tool also has a global
rating scale. This article collection features two of the original
papers19,20 that evaluated the validity and reliability of the APP and a
more recent paper21 offering an alternative scoring protocol and
interpretation. The validity study19 performed Rasch analysis on data
from nine universities to establish construct validity and unidimen-
sionality of the tool. These findings supported the summing of the
20 items to provide an overall score of clinical competence between
0 and 80 (ie, a one-factor model). Furthermore, the tool was able to
discriminate four levels of competence using the global rating scale.
The APP item scales performed in a consistent way regardless of the
characteristics of the student, clinical educator or placement context.
The reliability study20 established high inter-rater reliability on 5-week
clinical placements. Together, these studies provided confidence for
physiotherapy educators to use the APP to assess entry-level compe-
tence and the APP has subsequently been adopted by all entry-level
physiotherapy programs in Australia and New Zealand. Some univer-
sities in at least nine other countries already use the APP or are
translating it. The third APP paper21 differed from the previous cross-
sectional studies19,20 by using an archival, longitudinal study design to
progress the psychometric evaluation of the APP tool. This paper pri-
marily set out to establish whether clinical performance scores ob-
tained via the APP were best represented by one or two factors. Using
factor analyses, the results demonstrated that clinical performance
using the APP are best characterised by two factors, representing
professional skills (items 1 to 4) and clinical skills (items 5 to 20).
Furthermore, these interpretations and item scaling were mostly
consistent over time (across four clinical placements) and placement
context (cardiorespiratory, neurology, musculoskeletal and miscella-
neous). A large scale, multi-site (approximately 20 universities across
Australia and New Zealand) replication study is currently underway to
determine the robustness of these findings across different sites,
geographical locations and supervisor demographics.
Several additional avenues for future research are recommended in
the papers in this article collection. Rivers et al22 suggested exploring
career satisfaction and non-financial incentives for choosing and
maintaing a career in physiotherapy. Peiris et al9 recommended
examining private practitioners’ views on clinical education. Dario
155
et al15 recommended integrating clinical education at the inception of
research studies. Future research should target emerging areas of
physiotherapy practice and workforce development needs such as
those detailed in the Australian Physiotherapy Association’s recent A
Strong Physiotherapy Workforce for a Healthy Australia publication,23
which covers areas such as preventative health, aged care, mental
health24 and Aboriginal and Torres Strait Islander health.
Footnotes: Nil.
eAddenda: Nil.
Ethics approval: Not applicable.
Competing interest: Nil.
Source(s) of support: Nil.
Acknowledgements: Nil.
Provenance: Invited. Peer reviewed.
Correspondence: Mark Elkins, Centre for Education & Workforce
Development, Sydney Local Health District, Sydney, Australia. Email:
mark.elkins@sydney.edu.au
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